A study published March 6 in The Lancet Regional Health — Americas highlights a growing divide in cardiovascular health in the U.S., showing that wealth and education play a significant role in heart disease risk.
The research, led by Salma Abdalla, MBBS, DrPH, an assistant professor of public health at Washington University in St. Louis, reveals that the top 20% of high-income, college-educated Americans have far lower rates of cardiovascular disease than the rest of the population — disparities that have widened over the past two decades.
Abdalla initiated the work while at Boston University’s School of Public Health before joining WashU’s newly established School of Public Health.
Cardiovascular disease (CVD) remains the leading cause of illness and death in the U.S., but this emerging research highlights diverging trends; the remaining 80% of the population continues to face higher risks, reflecting the nation’s growing income gap.
Despite the U.S. spending more on health care per person than any other high-income country, outcomes continue to lag behind, particularly for those with lower incomes and less education. Life expectancy for the richest 1% of Americans is now 10 years higher than for the poorest 1%. These outcomes have worsened compared with other high-income countries.
The study analyzed 20 years of data from nearly 50,000 adults who participated in the National Health and Nutrition Examination Survey between 1999 and 2018. Participants were grouped by income and education. Researchers examined the prevalence of four major cardiovascular conditions: congestive heart failure, angina, heart attack and stroke.
Statistical models showed that low-income non-college graduates had 6.34 times the odds of congestive heart failure, 2.11 times the odds of angina, 2.32 times the odds of a heart attack and 3.17 times the odds of a stroke, compared with their wealthier, college-educated peers.
Disparities persisted even after adjusting for demographics and health markers such as body mass index, blood pressure and cholesterol levels. High income and education consistently correlated with better heart health.
The findings suggest that income and education play a complex role in shaping heart health, with future studies needed to examine their interaction. The differences observed in the burden of CVD, even after accounting for certain biological and lifestyle factors, may be attributed to multiple, intersecting reasons. For example, a lack of economic security can contribute to chronic physiological stress. Higher-income and more educated patients may have cumulative structural access to health-promoting behaviors and activities throughout their lives. Additionally, they are likely to receive more thorough medical care with better continuity and earlier interventions. They may also demonstrate better medication adherence, experience lower environmental toxin exposure and benefit from stronger support systems.
“The accumulation of economic and educational advantages appears to drive better health outcomes, rather than any single factor alone,” Abdalla said. “Wealth and education cluster among a small, advantaged group, while the majority of Americans face an increased risk of heart disease.”
Addressing CVD, she said, requires more than expanding health-care access. It also demands policies that promote long-term broad access to economic opportunity and educational equity, breaking down structural barriers.
The study’s senior author, Sandro Galea, MD, DrPH, the Margaret C. Ryan Dean of the School of Public Health and the Eugene S. and Constance Kahn Distinguished Professor in Public Health at WashU, emphasized the policy implications of the findings.
“The continued widening of health disparities in the U.S. underscores the need for action,” Galea said. “If we want to improve public health outcomes, we must address the root causes — economic opportunity, education and access to resources that support long-term health.”
This research was funded by The Rockefeller Foundation and involved collaboration with the School of Social and Political Science at the University of Edinburgh and the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital.
